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7161. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44693/psn-pdf
      June 15, 2016 - Safety. June 15, 2016 Center for Health Design. https://psnet.ahrq.gov/issue/safety-0 Elements of the health care work environment can affect the care delivery. This website highlights design considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections. The collect…

7162. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38602/psn-pdf
      January 14, 2025 - World Hand Hygiene Day. January 14, 2025 World Health Organization https://psnet.ahrq.gov/issue/save-lives-clean-your-hands This global initiative raises awareness about hand hygiene as a strategy to reduce health care–associated infections. The initiative highlights Save Lives: Clean Your Hands, an annual promoti…

7163. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44137/psn-pdf
      May 13, 2015 - AHRQ Patient Safety YouTube Channel. May 13, 2015 Rockville, MD: Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/ahrq-patient-safety-youtube-channel This Web site hosts a collection of training videos to highlight two improvement strategies: the Comprehensive Unit-based Safety Program and …

7164. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41833/psn-pdf
      November 14, 2012 - Risks related to patient bed safety. November 14, 2012 Sharkey JE, Van Leuven K, Radovich P. Risks related to patient bed safety. J Nurs Care Qual. 2012;27(4):346-51. doi:10.1097/NCQ.0b013e318264744b. https://psnet.ahrq.gov/issue/risks-related-patient-bed-safety Reviewing the three major contributing factors to me…

7165. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841489/psn-pdf
      December 14, 2022 - Rise to Health Coalition. December 14, 2022 Boston, MA; Institute for Healthcare Improvement: December 2022. https://psnet.ahrq.gov/issue/rise-health-coalition Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative for collective work to address four areas of e…

7166. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43145/psn-pdf
      June 15, 2014 - The 2013 John M. Eisenberg Patient Safety and Quality Awards. June 15, 2014 Jt Comm J Qual Patient Saf. 2014;40(5):195-218. https://psnet.ahrq.gov/issue/2013-john-m-eisenberg-patient-safety-and-quality-awards Articles in this special issue highlight the achievements of the 2013 John M. Eisenberg Patient Safety and…

7167. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46442/psn-pdf
      October 04, 2017 - Handoff Communication. October 4, 2017 APSF Newsletter. October 2017;32:29-56. https://psnet.ahrq.gov/issue/handoff-communication Handoff processes are known to carry risks of communication errors. This special issue focuses on transfers involving anesthesia care. Articles review different types of handoffs, chara…

7168. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41063/psn-pdf
      January 27, 2012 - Perspective: ten thousand hours to patient safety, sooner or later. January 27, 2012 Pellegrini VD. Perspective: ten thousand hours to patient safety, sooner or later. Acad Med. 2012;87(2):164-7. doi:10.1097/ACM.0b013e31823f7202. https://psnet.ahrq.gov/issue/perspective-ten-thousand-hours-patient-safety-sooner-or-…

7169. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37243/psn-pdf
      December 16, 2011 - Raising the awareness of inpatient nursing staff about medication errors. December 16, 2011 Elnour AA, Ellahham NH, Qassas HIA. Raising the awareness of inpatient nursing staff about medication errors. Pharm World Sci. 2008;30(2):182-90. https://psnet.ahrq.gov/issue/raising-awareness-inpatient-nursing-staff-about-…

7170. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36388/psn-pdf
      June 12, 2013 - Using patient safety science to explore strategies for improving safety in intravenous medication administration. June 12, 2013 Franklin M. Journal of the Association for Vascular Access. 2006. 11(3):157–160. https://psnet.ahrq.gov/issue/using-patient-safety-science-explore-strategies-improving-safety-intravenous-…

7171. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34617/psn-pdf
      March 07, 2005 - World Alliance for Patient Safety: forward programme. March 7, 2005 Geneva, Switzerland: World Health Organization; 2004. https://psnet.ahrq.gov/issue/world-alliance-patient-safety-forward-programme This report outlines the six goals set by the new world alliance to achieve what no single country could accomplish …

7172. The Need to Eat | PSNet
      psnet.ahrq.gov/web-mm/need-eat
      February 10, 2021 - August 31, 2011 Reducing warfarin medication interactions: an interrupted time series

7173. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet
      psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
      March 25, 2020 - Proper planning and execution of the CABG operation has been shown to prolong life by reducing rates

7174. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36810/psn-pdf
      November 19, 2014 - A Systems Approach to Quality Improvement in Long- Term Care: Safe Medication Practices Workbook. November 19, 2014 Massachusetts Coalition for the Prevention of Medical Errors, MassPRO, Massachusetts Extended Care Foundation. Boston, MA: Commonwealth of Massachusetts; 2008. https://psnet.ahrq.gov/issue/systems-ap…

7175. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38822/psn-pdf
      July 29, 2009 - The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. July 29, 2009 Stahel PF, Mehler PS, Clarke TJ, et al. The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. Patient Saf Surg. 2009;3(1):14. doi:10.1186/1754-9493-3-14. https://psnet.ahrq.gov/issue/5th-annivers…

7176. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42311/psn-pdf
      May 29, 2013 - We know what they did wrong, but not why: the case for 'frame-based' feedback. May 29, 2013 Rudolph JW, Raemer D, Shapiro J. We knowwhatthey did wrong, but notwhy: the case for ‘frame-based’ feedback. Clin Teach. 2013;10(3):186-189. doi:10.1111/j.1743-498x.2012.00636.x. https://psnet.ahrq.gov/issue/we-know-what-th…

7177. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38530/psn-pdf
      April 01, 2009 - Assessing the impact of an educational program on decreasing prescribing errors at a university hospital. April 1, 2009 Peeters MJ, Pinto SL. Assessing the impact of an educational program on decreasing prescribing errors at a university hospital. J Hosp Med. 2009;4(2):97-101. doi:10.1002/jhm.387. https://psnet.ah…

7178. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48026/psn-pdf
      July 10, 2019 - Network of Patient Safety Databases. July 10, 2019 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/network-patient-safety-databases The Patient Safety Organization (PSO) program seeks to gather and analyze nonidentifiable patient safety incident data to track concerns and reduce risks. Thi…

7179. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39344/psn-pdf
      March 03, 2010 - Mistake-proofing healthcare: why stopping processes may be a good start. March 3, 2010 Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007. https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…

7180. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50771/psn-pdf
      May 29, 2024 - AHRQ Health Literacy Universal Precautions Toolkit. 3rd edition. May 29, 2024 Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication No. 15-0023-EF. https://psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-2nd-edition The AHRQ Health Literacy Un…